This specification provides the definition of the Interactive health insurance eligibility and benefits inquiry and response (IHCEBI) to be used in Electronic Data Interchange (EDI) between trading partners involved in administration, commerce and transport.

The Interactive health insurance eligibility benefit inquiry and response message may be used for both national and international applications. It is based on universal practices related to administration, commerce and transport, and is not dependent on the type of business or industry.

In particular, IHCEBI can be applied to all types of health care service providers, funding institutions and health care delivery systems.

The IHCEBI message is sent from institutional or individual health care providers or those providing related administrative services to a funding institution to obtain health insurance information from a patient’s health plan prior to or at the time of admission or treatment.

This inquiry message will allow a health care provider to give their patient an estimate of cost for certain treatments, or assess their own financial risk associated with certain treatments, and provide the patient with informed financial choices regarding their health care options.

Each inquiry can provide information to the health plan about a service being considered, (e.g., actual or expected service dates, actual or expected duration of hospital stay, and planned services). An inquiry can also contain information about the treating and referring practitioner, if they are not the health care party making the inquiry.

The response message will provide information regarding what benefits are available to the patient based on their health plan contract and the information provided with the inquiry. This can include financial information, such as, co-pay amounts, deductible amounts, limitations, and exclusions.

Each response can also provide information regarding administrative issues concerning a covered benefit, such as, indicate who is the primary provider for a service, contact information for the health plan and patient, and policy rules, such as, certain screening exams can only be done once every two years.

The Interactive health insurance eligibility and benefits inquiry and response may be used for both national and international applications. It is based on universal practice related to administration, commerce and transport, and is not dependent on the type of business or industry.

The IHCEBI message can carry either an initial inquiry, modifications to an inquiry made in a previous eligibility request and response message from the funding institution.

An inquiry can only concern one patient or health plan subscriber, but may concern one or more services or procedures regarding an individual patient or subscriber. A response is limited to providing an answer to the questions asked about a patient or health plan subscriber, but may report benefits for multiple family members.

Capitated provider - is a term that describes a provider who is under contract with a health plan and the provider agrees to receive a monthly capitation payment amount per patient each month in lieu of fee for service payment or charges. Under this arrangement a provider cannot charge for services rendered that are described in their contract, for example, routine well visits or sick visits.

Use to specify the message and processing requirements, for example, the type of health care insurance verification to be done and to provide a tracking mechanism for the submitter of the message. The reference number in this segment will provide an application level tracking number, which is different from what is generated in the message envelope.

Associated Parties Group: A group of segments that will be repeated once for each party involved with this eligibility message, used to identify and provide information about each party by code and name. Parties may include and a loop would be present for: 1) Submitter - when serving as an agent for the provider, 2) Requester - either a provider, payer, or employer making a request, 3) Responder - either a payer or a third party administrator when serving as an agent for the payer, 4) Subscriber - will always be present, and 5) Patient - present only when patient is not the subscriber.

In the response message the responder may optionally add one or more entries to this loop to identify a patient's primary care physician (PCP) or specialist, if the provider making the inquiry is not the patient's PCP or specialist. Other parties may also be added to identify other capitated providers associated with the patient care and health plan.

To provide specific entity identifiers or demographic information regarding the identity of the participating parties. For individuals identifiers will include date of birth, or a health plan insurance card date of issue as shown on the card may be specified in this segment, when the segment is identifying a health plan subscriber.

Use to specify a party identity, and when necessary, the name and address of an entity and their related function in either a structured or unstructured format. For use in health care, it is recommended to use only the name and identifier, but when name and address are required use only the structured method of submittal. This segment is providing the name and address of the party identified in the Associated Parties Group.

Use to specify contact communication numbers, names, and electronic message routing information. Use to provide information about contacts within an organization or associated with the party identified in the Associated Parties Loop who can be called upon for further or clarifying information. The reference number may be used to provide a unique number for the contact entity to use when referring to this message.

Used only with the response message, this will identify specific corrective actions or follow-up that should occur before another inquiry is made about this entity. Errors reported here related to the parties identified in the Associated Parties Group. For example, provider is not authorised to inquire against this payer's files.

Global Benefit Service Details Group: This group of segments will occur only once for an eligibility request or response. It provides coverage or service information that is common for each health insurance benefit and service coverage reported.

Use to specify dates that will common to each benefit or covered service.

On the request message, this segment will be used to specify the service or planned service dates for the benefits in question.

On the response message, this segment will specify the effective dates of benefit coverage for all listed benefits. The information in this segment can be overridden for a specific benefit, when effective or termination dates are different from the overall plan. This is done in the Health Insurance Benefit Details Group for each reported benefit where it applies.

To identify specific corrective actions or follow-up that should occur before another inquiry is made about the patient in the request message. This segment is only sent with the response message when there are errors to report related to the benefit information request message within the Global Benefit and Service Coverage Group. For example, an invalid service date or insurance type was specified.

Health Insurance Benefit Details Group: This segment group provides health insurance coverage and benefit information about a particular person’s health insurance plan. This segment group can be repeated to describe each benefit or covered service in question. Each benefit or covered service will require a separate repetition.

When this message is sent as a request for health insurance available benefits and coverage, it will specify the type of health benefit information that is required.

When this message is sent in response to a request, this segment group will provide the requested health insurance coverage and benefit information as requested by the inquiry.

When used on the request message, it will specify a specific benefit or covered service in question.

When used on the response, it will provide information about the requested health insurance benefits and coverage available, plus any additional administrative information that may have a business or patient care impact to the party making the inquiry.

Use to specify diagnosis information and procedure or therapy services and details about how and when these services can be delivered, based on the diagnosis or procedure or contract terms or all of these.

When this information is sent on the request, it is describing the diagnosis of the patient and asking about benefit coverage for a specific procedure or therapy.

When the information is sent on the response, it is providing information from the health insurance plan about what benefit coverage is available, for certain procedures based on the diagnosis and what service delivery requirements exist, which can vary based on diagnosis, procedure, and health plan contract.

Use to specify eligibility dates related to the benefit or service described in the current iteration of the Health Insurance Benefit Details Group.

When used at this level on the request message, it is to specify service dates from the provider that are outside of the service dates specified in the Global Benefit Service Details Group.

When used at this level on the response message it identifies eligibility start or termination dates assigned by the responder that override the overall eligibility dates identified in the earlier Global Benefit Service Details Group.

Use to reference a specific payer or provider for the benefit or service identified in the current Health Insurance Benefit Details Group. The payer or provider should be in the list of parties identified within the Associated Parties Group, where full details of the entity should be provided, including name, address, and contact information. The payer is most likely used for third party liability for coordination of benefits. Identified providers would be those restricted to providing services for the identified benefit, for example, a capitated provider.

Use to identify specific corrective actions or follow-up that should occur before another inquiry is made about this subject entity, that is, the patient or health plan subscriber. Errors reported at this level of the message are benefit specific, reporting processing errors from the responding application associated with the benefit inquiry request.